a16z Podcast - The Science and Supply of GLP-1s

Episode Date: June 19, 2024

Brooke Boyarsky Pratt, founder and CEO of knownwell, joins Vineeta Agarwala, general partner at a16z Bio + Health.Together, they talk about the value of obesity medicine practitioners, patient-centric medical homes, and how Brooke believes the metabolic health space will evolve over time.This is the second episode in Raising Health’s series on the science and supply of GLP-1s. Listen to last week's episode to hear from Carolyn Jasik, Chief Medical Officer at Omada Health, on GLP-1s from a clinical perspective. Listen to more from Raising Health’s series on GLP-1s:The science of satiety: https://raisinghealth.simplecast.com/episodes/the-science-and-supply-of-glp-1s-with-carolyn-jasikPayers, providers and pricing: https://raisinghealth.simplecast.com/episodes/the-science-and-supply-of-glp-1s-with-chronis-manolis Stay Updated: Let us know what you think: https://ratethispodcast.com/a16zFind a16z on Twitter: https://twitter.com/a16zFind a16z on LinkedIn: https://www.linkedin.com/company/a16zSubscribe on your favorite podcast app: https://a16z.simplecast.com/Follow our host: https://twitter.com/stephsmithioPlease note that the content here is for informational purposes only; should NOT be taken as legal, business, tax, or investment advice or be used to evaluate any investment or security; and is not directed at any investors or potential investors in any a16z fund. a16z and its affiliates may maintain investments in the companies discussed. For more details please see a16z.com/disclosures.

People have no idea what's coming and how big of an innovation this is going to be. One of my earliest experiences in health care was my pediatrician telling my mom that I should go to fat camp. Specialist obesity training. They're typically missing a few things. The average one will have four hours of training in obesity in medical school. We're actually all users of gLP ones. There we go. So GLP1 is a hormone that we all have. Obesity, a choice or a condition. Well, regardless of what you believe, this chronic disorder continues to impact millions of Americans,

with nearly 70% of Americans fitting the description of overweight or affected by obesity. And moreover, 55% have canceled appointments due to the anxiety of being weighed, at least according to Known Well. Known well as a company trying to rethink obesity medicine, and its founder and CEO, Brooke Boyarski-Platt, joins A16C general partner Vanita Agrawala. Together, they discuss what it will really take to change some of these statistics and how new technologies like GLP-1s fit into this mix. Brooke herself has personal experience in this domain as a former patient with obesity,

having even been told by her pediatrician that she has to go to a fat camp. Now she's using that fuel to rethink obesity care herself. Now this episode was also part of our sister podcast Raising Health's GLP1 series. And if you've been paying attention over the last year, GLP ones went from being an unassuming acronym to a familiar class of drugs that some recent studies have even pegged as many as one in eight Americans trying. The recent adoption of these drugs has also springboarded companies

like Novo Nordisk, the manufacturer of Ozympic, to the largest company in Denmark. So if you, like many others, are interested in learning more about GOP-1s, make sure to tune in to the rest of the series on Raising Health. You can find a link to the show, or the full series, in our show notes. Let's get started. Hello, and welcome to Raising Health, where we explore the real challenges and enormous opportunities facing entrepreneurs. who are building the future of health.

I'm Olivia. And I'm Chris. You're joining us for the second episode in our deep dive series on the science and supply of GLP-1s. Last week, we heard from Carolyn Jasek, chief medical officer at Omata Health. If you haven't listened to that one,

it's a great primer on GLP-1s from a clinical experience. Today, we'll hear from Brooke Boyarski-Pratt, the founder and CEO of Knownwell. Next week's episode, we'll be with Kronis, of UPMC health plan on the pharmacy implications of GLP-1s. Brooke talks with Vanita Agrawala, general partner of A16Z bio and health, about the value of obesity-specific practitioners, patient-centric medical homes,

and how she thinks the metabolic health space will evolve over time. If a patient is given a choice, they prefer a medical home. And that's what we've seen with our patients. So we've seen a lot of patients leave point solutions because they say, wow, you can also do my primary care. I can occasionally see you in person. and you were a real doctor who I talk to and who I have a care team I know and respect.

So I think that's really important, particularly as it relates to symptom management. You're listening to Raising Health from A16Z, Bio and Health. I am incredibly excited to welcome to the Raising Health pod today, Brooke Boyarski-Pratt, founder and CEO of an incredible company called Knownwell that we've had the real privilege of partnering with recently. Brooke's here to join us to share a little bit about how she's looking at the obesity medicine space as a whole, the role that she hopes known well will play there, and a little bit about why she's building the company at a personal level.

So Brooke, I'd love for you to just introduce yourself and share the story behind this company. Yes, such a pleasure to be here. Thank you so much, Vanita, for having me on. I am a patient. I mean, that's really what brought me to known well. and ultimately led me to founding it. I'm someone who's been in a larger body my whole life. You know, one of my earliest experiences in health care was my pediatrician telling my mom that I should go to fat camp. And that really, you know, unfortunately started

the process of how I viewed interacting with the health care system when it came to my body size. And as I got older and sort of, you know, had different educational and work opportunities, it led me to move a lot. And every time I moved and reestablished primary care, I felt like I was needing to reestablish the idea that I was a thoughtful person who took my health care seriously. Not for any fault of the primary care doctors I met with.

They just have a lot of patients every day, and I'm sure it's frustrating for them to see so many patients struggling with the same disease state. So I was dreading going to the doctor. And it was even harder when I was actually looking for treatment for my metabolic. health to find something that was accessible to me. And in my very last move, when I was walking to my new PCP for the first time, I started getting curious about if other people feel that same dread, other people who were like me.

And I was overwhelmed by the research. And I'll just say briefly, that was kind of the nights and weekends I started pursuing this passion of could we really create a patient-centered home for people, with overweight and obesity. Well, in the venture world, you know, investors talk about founder market fit, and I cannot imagine a more compelling and more deeply connected founder to build a company that's going after tackling not only the bias and access and comfort issues that patients face, but also the care quality.

Let's talk for just a second about your professional. background, though, because it's also really interesting that while you've had that patient journey and patient connection to the obesity medicine space, you didn't come from health care. So you look a little different than some of our other healthcare portfolio CEOs and leaders in the healthcare space. But you're remarkably proficient and picked it up so fast and are so compelling now. But what made you jump? You know, you had a background in finance and consulting. Yeah, you know, very traditional kind of business background of Penn and Herbert Business School of McKinsey and worked at a commercial real estate company. So certainly not in health care. I joke that I'm sort of

glad I didn't know what I was getting myself into when I jumped into Known Well and creating the company. But ultimately, I had always hoped that I would one day find something to work on that I felt was my life's work. And before Known Well, what I was always drawn to was doing a good job, delivering for clients and being the best colleague and boss I could be in terms of the people I worked with. But if I'm being honest, there wasn't a day that I woke up and thought, I am so passionate about commercial real estate today, right? I mean, it was just something that was important to do well and to deliver for people. But as I started, I had always been drawn to health care, like just to the healthcare industry, because I always felt like,

how could you have a more direct impact on people than in health care? And I'd always joke with my physician friend that they made the right decision going into healthcare. So it almost sort of came together naturally that as I started to feel like there was an opportunity here to really touch a group that had been underserved, even though it's been a steep learning process, it sort of felt natural that I found my way to health care. consider me one of your physician friends who is very happy to have you join the forces in healthcare. Let's talk a little bit about what obesity and overweight management and medicine

actually is. We've already used the term a few times. So let's backtrack for our listeners for a second and just, you know, make sure we're all on the same page. What is obesity medicine? Like, is that a specialty? What is it? It is a specialty. So if we take a take a step back, you know, overweight and obesity is defined by BMI. We could have a whole podcast about how that's not the best measure to use, but it's the best and sort of easiest measure we have today to diagnose the disease, right? So this is really about living in a body where your weight is higher than your height would suggest on a bell curve and that puts you in to overweight and obesity. And it was not long ago. I mean, the reason Medicare for

example, doesn't cover obesity treatment, is they see it as a cosmetic disease. And it wasn't long ago that that's how everyone viewed overweight and obesity. You know, in 2012 was the first ever board certification in obesity. So that's how recently this disease state has been, you know, really viewed as something in the medical community. And obesity medicine is really about comprehensive treatment of the state of obesity and overweight. And if a person is interested in intentional weight loss, really helping them on that path, both to address the obesity and also potentially other metabolic health conditions, such as diabetes, hyperlipidemia, that can sometimes go with these diseases. So typically a clinician who practices obesity medicine is a primary care doctor

from their medical school and residency days, though not always. You can see cardiologists and OBGYNs who do have a board certification and obesity. And nowadays, we have fellowships. So some folks go and do an obesity medicine fellowship. And then we also have a board certification. And I'll note it's actually the fastest growing specialty in the U.S. And there's something called the Obesity Medicine Association, which is the largest association of clinicians who practice obesity.

and we're really fortunate that my co-founder and our CMO, Angela Fitch, is the president of it. So what about a primary care doctor like me who has an overweight or obese patient who I'm really trying to figure out how to serve? Help us understand the bridge between all primary care physicians in America and the subset of physicians who are trained to deliver obesity, medicine, care, and certified to do so. given that we have a situation where over 40% of all Americans actually fit that definition. Totally. And as we mentioned earlier, everyone's doing their best, right?

So what I don't think the differences between a primary care doctor who practices and doesn't is how much they wish to help the patient. So a PCP who doesn't have, you know, specialist obesity training, they're typically missing a few things. the average one will have four hours of training in obesity in medical school. This is an unbelievably complicated disease, right? So very little formal education on obesity, typically very little continuing education on the innovations that are coming on to the market.

So in addition to an education. Yeah, which we'll talk about. In addition to the education issue, though, they're also typically lacking the resources where they practice. So to practice really great obesity medicine, we also want things like dietitians, health coaches, a movement program ideally, behavioral health, and even like a good prior authorization process

if you incorporate anti-obesity medications. So most primary care doctors are practicing without any of those additional services. And what they'll say to us all the time is, look, I suppose I can prescribe something. I don't even really understand the meds. I don't understand how to get them approved. And the truth is I know the patient needs more help,

and I don't have the services to help them. Whereas someone who's been an obese who's obesity specialized, not only has the formal education and the continuing medical education, but they are typically part of weight centers or other groups that have the wraparound services. You mentioned Dr. Fitch. That's exactly her background.

She's set up weight centers in multiple, you know, places in the country, both health system affiliated and now at Known Well. You mentioned she's president of the Obesity Medicine Association. But if you could sort of channel her thinking, your thinking, known well's thinking on this topic, what are the key pillars of comprehensive evidence-based care for patients with overweight and obesity. So there's something called weight normative medicine and weight inclusive, and it's a way we practice using the broad we here. Weight normative is you should be, you know, I'm 5'4, you should be 150 pounds, and every time you come to the office, I'm going to tell you you should be 150 pounds.

It turns out patients actually gain more weight when they have experiences like that. The other approach is called weight inclusive, which is, hey, Brooke, I recognize you're not 150 pounds today. Let's work on the wellness goals, and actions you can take, inclusive of your current body size. And what's really interesting is the research suggests that that actually leads to much better health outcomes, right? So at its core is the approach around how do we work with patients. Then there are multiple pillars of the actual actions we take. So typically, though not always an anti-obesity medication will be used and we'll talk more

about those, typically a nutrition program is used. either one-on-one coaching with a dietician or group classes. You want to address sleep and stress management that could go as far as someone to undiagnosed sleep apnea and could be as light of an intervention as meditation, right, and other things that we work on with patients. Ideally, you would include a movement program, which we do, health coaching and remote patient monitoring. So allowing that connectedness to the clinic of having a scale at home, if you have heart disease, having a blood pressure cuff at home, a connected glucometer and working with a health coach.

And lastly, really a behavioral health, right? So to the extent that a patient is interested in working on their behavioral health in addition to the other medical components, those taken together are really considered the core comprehensive program for obesity management. Amazing. And referrals to surgeries and other interventions as needed to wrap around. that wrap around the medical care, the right interventions have to be matched to the right patients, as with all of medicine. And I'll also note that one of the things I've learned from you all

is just kind of a better awareness of how much of an adolescent problem we have as well in this country and around the world. But we've got 14 million American children and teens also living with obesity. And so this isn't just an adult medicine or an adult primary care challenge in front of us. one that affects the pediatric community. That's a community that's even less trained on the whole in managing conditions and comorbidities associated with obesity and overweight. So I think it's just we have a really important opportunity ahead of us in our health care system to get this right, to get obesity and overweight evidence-based care right and to do it at scale. So incredibly excited about what you're building. Let's double click on one of the pillars that you

mentioned, which are obesity medicines. And not a day goes by at this point where GLP-1s are not headlining news stories, whether it's around cost, access, new drugs, new therapies, oral versions of the therapies. You know, anyone reading healthcare news at this point is basically inundated with GLP-1 headlines. What are GLP-1s? Yeah, you know, we're actually all users of GLP-1s. There we go. In the sense of GLP-1 is a hormone that we all have. It has a lot of different functions, but primarily it helps with insulin regulation as we eat and consume food. It affects the speed of digestion after we eat. And it also affects the feeling of fullness. So kind of the signals that go to our brain. So what a GLP-1 therapy is going typically is going to do is

mimic the hormone that we have naturally occurring in our body. And then you'll hear about things like dual and triagonists, which is, you know, as these drugs get more advanced, they're mimicking additional hormone pathways. So, you know, simply just kind of stacking on top of each other more of the pathways that we believe impacts obesity as well as, of course, diabetes. And, you know, what I'll mention with GLP ones and what Angela would say if she were on the phone with us, Dr. Fitch, they've been around a really long time, right? The first GLP-1 was approved by the FDA in 2005. So we often talk about it as if these came out of thin air.

But the truth is, especially endocrinologists and physicians to have been in the obesity space for a long time, have been using these medications. When did you first learn about these medications and their potential, and what role did they play in your conception of impact at Nonwell? 2018 was a big year for me, because first, it was the first time I had ever heard about obesity medicine, had never heard of it as a subspecialty, and I had seen a primary care doctor in Philadelphia, and she knew I was struggling with my weight, and she said, well, you should see

Dr. Janine Krollos. She's a leader in the field in Philadelphia, and she practices obesity medicine. And I was like, there are people who could just help me. So I saw her, and she was the first person who talked about Ozempic with me. And I thought it was just absolutely wild. I was like, there's an injectable, and it helps with weight. Of course, at the time was being used just to treat diabetes. So that was the first time I had heard of it. Obesity medicine physicians were using it off a label at that point to talk about, to treat obesity. But it's really interesting that I feel like I actually ended up hearing about it much earlier than it sort of came on to the mainstream. but it's not a surprise that people who knew what they were doing,

knew how big of a deal it was. And I'll say when I first started talking to Dr. Fitch in 2020, when it was a little bit more getting into the public eye, she was just like people have no idea what's coming and how big of an innovation this is going to be as these get more obesity indications approved by the FDA. So she was certainly a fortune-tower. Yeah, the weight last data was staring us in the face

in the diabetes trials. So it is, all the dates you just mentioned, 2018, 2020 are well in advance of kind of the current moment in time when GLP-1 receptor agonists have reached peak public awareness. But it is interesting to reflect on that that data was sort of staring us in the eyes. What maybe wasn't as obvious just because the studies hadn't been done specifically in patients who do not have diabetes but have obesity, what was not maybe as obvious. was just the role that they would play outside of diabetes specifically for the indication of weight loss. But at this point in time, they're in the arsenal. What are some of the

biggest myths about GLP-1 drugs? One is that they're a miracle that works for everyone. They are our most effective treatment, right? That is no question. But when you look at the data on semaglite slash ozempic, right, 40% of patients will lose 20% of of their body weight. So that means 60% of patients won't lose, you know, 20% of their body weight. So that's a lot of folks. And the data gets better as you get with newer medication. So Trezepotide is 60% of patients lose 20% of their body weight, which still means you have 40% who don't. And the reason I think that's so important to call out is one, it's important you get the right medication with the right patient, which is not always a GLP1. They may not be a

responder. And the second is, boy, for the patients who fall in that 60% or that 40%, unfortunately, they can feel like a failure. You know, folks who have already felt like failures this whole time with their weight, oftentimes, and then when they don't turn out to be a responder, I think that's where we need to improve the education so that there isn't this shame and stigma around the disease state and the person. The second thing I would say is that there's a myth around the tolerability of these drugs. So you see a lot of PBM data and other data sets that show, you know, after one year, only 40% of people are still on the drug. And that's often used to show there's a lot of waste, you know, there's a lot of issues with the medication. First,

sometimes this data, they're not always, is confounded by the fact that people lose access to the medication, right, from their insurance or they move jobs or whatever. But even for the people who stay on, what we have found in our clinic with our own research is well over 90% of our patients stay on the medication. And we think the difference is really twofold. One, it's better understanding the patient before you put them on the medication. Full health history, family, are you putting the right person on the right medication? And then the second is actively managing the symptoms of those patients. So we know exactly what to expect for certain archetypes of patients when they start a medication, whether it's phentermine or, you know,

Manjaro. So we are able to say like, hey, we expect in three days you could start to experience nausea. Actually eating small meals and making sure you start in the morning, even if you're not hungry, will help curve that nausea, right? So things you can do to really better educate the patient and actually reduce those side effects over time. So I think those are kind of two important myths. I would say there is one last one that doesn't come up quite as often, which is around food quality. A lot of times people say the food quality no longer matters. Patients can really eat whatever they want if they're on these medications because they're so effective at reducing and curbing appetite. The last thing I'd say about that is actually we have pretty good research

to show that maintaining or increasing protein intake is unbelievably, it's more important on these medications. It's actually more like having had bariatric surgery. So when we work with our patients, we have such a keen focus on things like protein intake, even if that means having to supplement occasionally with a protein bar or shake, because it can be really dangerous to the patient's long-term health to have them, you know, losing a lot of muscle mass. Especially their muscle mass. Yeah, exactly. I think sometimes that detail gets lost in the headlines. So let's come back to that 40% of patients who even under his epitide do not sort of hit the weight loss goal that they might have set jointly with their doctor. Can you just educate us on what some of the both

medical and non-medical interventions that we might be able to offer that subset of less responsive patients are? Absolutely. So as I first mentioned, there actually could be a medication that's better for that patient. You know, interestingly, you'll find sometimes that patients who are high responders to phentermine, by the way, a drug that's like $10 a month if you get a generic are better or higher responders than patients for GL, than that patient would be for a GLP1. Part of that, we think, is the biological process around what's driving the obesity, that they actually respond better to different medications. So first is making sure that we're trying different medical therapies and combination therapies to see if there's a more effective medication

for them. You know, ideally, actually, you're starting with that therapy and moving up to DLP ones. The second, of course, is bariatric surgery. There's a big belief in the market that bariatric surgery is going to tank. We actually, we have a little bit of a contrarian view there. We feel so many more people are finally seeking treatment that for a period of time, we actually could see an increase in bariatric surgery because people are finally having these conversations with physicians. So, you know, bariatric surgery, particularly for a higher BMI individual, especially if they have a comorbidity, in today's world, maybe not with innovations 10 years down the line, but in today's world is a really effective treatment. And then there's like the things

there's like the nutrition therapy, the behavioral health, this is such a complicated disease state. And what we found with all of our patients is there's generally not a silver bullet. So how do you work across these different modalities and really problem-solve with the patient to understand what's going on? What do we know about the long-term impact of these drugs, especially in a world where so many patients are just getting on these drugs. But there exists, as you pointed out, an evidence-based of patients who have been on, you know, this drug class since 2005. So what do we learn from that body of data?

Yeah. So from that earlier data, which of course, as we talked about, it's going to be limited because it's certain types of patients who were being tested back then, they seem pretty darn safe, right? I mean, there are a few things like potential risk of thyroid cancer that have been called out from animal studies, but have never actually been replicated in human studies, right? Like, when you look at real world and clinical trial data, you are not seeing an increased risk of thyroid cancer for patients who have been on the medication for a long time. So generally speaking, obviously there are certain things that are coming out that are still being investigated like suicidal thoughts and other potential side effects that they'll

certainly keep following up on. But for the best data, you know, peer-reviewed, double-minded studies that we have today, there really aren't large concerning kind of pieces of evidence that we've seen in terms of longitudinal data. In fact, it looks like cautious optimism, but it looks like some of the long-term benefits of the drug class over the longer-term horizon for patients could be quite interesting with respect to cardiovascular disease risk, with respect to treatment, potentially even reversal of fatty liver disease and steatosis, potentially even an impact on addiction states and other behavioral health conditions. What do you make of that? How does Dr. Fitch have those conversations with patients who come to known well and are curious

about this range of impact. It's really exciting, right? I mean, like you said, the earlier the data, the more we want to be thoughtful about our excitement around it. But look, the select trial around cardiovascular risk was pretty darn compelling. Was it one large trial? Yes, right? So we're going to see more data.

Obviously, the study that came out around patients who are HIV positive a couple of days ago with their reduction in fatty liver was extremely exciting. doing actually a clinical trial and fatty liver. To your point, things like addiction, while it's early in the data, we see it in spades in our patients, right? So if you talk to a doctor in clinical practice, they will say, I would be shocked if the data doesn't end up proving out what we're seeing in our clinical practice. So the way Dr. Fitch generally talks about this is, again, we always want to be cautiously optimistic when the data is early, but it's really compelling. I mean, in my clinic even, I see cancer survivors and obesity and overweight is not the most common

complication in cancer survivors who've been through pretty aggressive therapy. But sometimes these other states, whether it's unexplained cardiometabolic profiles after a bone marrow transplant or fatty liver disease associated with prior steroid therapy and things like that. So there are all these indications that are popping up in places that, you know, I wouldn't necessarily have expected, but are really encouraging and make me optimistic about the drug class and the role it will play in improving health outcomes. Let's talk about access. Clinics like known well are playing an important role in figuring out how to scale access to these medications in a safe way and in a way that's evidence-based and consistent with where we want these drugs to go based on the evidence

that you outlined. So what is the best practice for prescribing these. drugs. How does a provider determine if a patient is eligible? Yeah, so we think the best practice includes a few things. So patient medical records. I know that sounds silly. But really, I mean, it's actually pretty rare in the GLP1 space right now. So understanding the longitudinal health history of a patient, what are their comorbidities? When did those comorbidities start? Right. So we get medical records on all of our patients, for example. As we talked about earlier, thorough kind of social and family history. Because while the data on things like thyroid cancer today aren't terribly compelling in terms of being nervous about it, if you have an aunt or a mom

who has had a specific type of thyroid cancer, we're going to have a much longer conversation about if a GLP1 is the right answer for you, just given the data we have today. So thoroughly understanding the patient from those kind of medical perspectives, understanding to have the emotional and behavioral elements of the obesity for the patient. We always talk about what was the age at which you started struggling with your weight, what's been your highest weight. Because for example, someone who may eat emotionally could actually need different kind of intervention from someone who actually just eats in excess at different times. Right. So there are different elements of how a patient relationship with food has evolved that may impact what their treatment

should be. So I think that's, you know, extremely important and something we spend a lot of time on. Third, of course, is what does the patient actually have access to? The worst thing you could do is tell a patient, after all of this evaluation, spending an hour with you live synchronously, I think you'd be an amazing candidate for Manjaro for Zepbound. And then you find out their insurance doesn't cover it, and it's a formulary exclusion. So for us, we try to have that information on the patient before they even walk in the door. And then the last element is really that synchronous interaction. We think it's helpful to occasionally see a patient in person, but we don't always.

But whether it's live or via video, again, it sounds a little bit silly, but like being able to see the patient understanding their emotional response when you're talking about different interventions, we think is really important. Couldn't agree more. It's not necessarily how all GLP. one, receptor agonist access is happening, though, today. No. And you're seeing it, we're seeing it, patients are seeing it.

There are emerging different channels through which medication access may become possible. There are still supply shortages and expense hurdles that make those channels not totally a turnkey solution. But going back to comprehensive obesity medicine, how do you think about where that goes in a world where there are other avenues by which patients are understandably looking to access, you know, medication that they think could really help them. If a patient is given a choice, they prefer a medical home. And that's what we've seen with our patients. So we've seen a lot of patients leave point solutions because they say, wow, you can also do my primary care. I can occasionally see you in person. You were

a real doctor who I talk to and who I have a care team I know and respect. So I think that's really important, particularly as it relates to symptom management. And comorbidities. By the way, I have comorbidities that are real medical conditions. Like we can also manage your diabetes and everything else. And we've had patients who say to us like, look, I was throwing up for four days. I ended up in the ER. I couldn't get anyone in the app to respond to me. Right. So I think there's a real patient safety and patient comfort in going to something that's more clinically oriented. But I think to your point, look, patients are so desperate for access that there will always be a role to play, whether good or bad in some instances, of kind of this more direct prescribing

with less interaction with the patient. But I think at their core, most patients, and I'll speak for myself, want to feel known well, right? Like, that's, if they can find that locally who takes their insurance, like, that is their preferred method. So I think both models will exist in the long term. The one thing I would add, though, is I do wonder if we'll see more scrutiny around that prescribing. You know, we have a physician who's joining us from another company who had said, like, look,

the big reason I'm leaving is a year ago, we stopped having any synchronous visits with patients. I get a survey and I'm filled out by the patient and I meant to prescribe and I've never even seen or talked to that patient synchronously. I'm going to go out a limb. I'm not a doctor and say, I don't know that that's a best medical practice. I could claim to be a 75-year-old man. And if you've never seen my medical record and you've never seen me, so I do think we'll probably, at the most extreme end, we'll see some curbing of that kind of behavior. What else will change with access going forward? So it's really important to note that obesity is one of the only disease states that's not a standard benefit on insurance.

I bet you've never been up a part of a conversation that says, is an employer or an insurer going to cover breast cancer? It's expensive, but we cover it. Are we going to cover diabetes? It's expensive, but we cover it, right? So I think obesity is more akin to what you've seen with fertility, where it was considered this carve-out rider, and that puts employers in the really tough position of, you know, when they're self-insuring or when they're going to, you know, going to payers and buying something off the shelf, it's not typically within the standard benefit. And that means they need to make a decision about if they're going to include it or not and are they going to raise their costs. So we think ultimately the most important thing for access, and Dr. Fitch was on the Hill on Monday advocating for Troa. It's getting Troa passed, which would have Medicare cover obesity, which would really be the first step in establishing obesity as a standard part of any insurance benefit.

Until then, we're left to each insurance company and each employer trying to navigate what's a really difficult solution. A situation. We do think over time access in terms of insurance is going to continue to improve. We see more Medicaid states approving obesity treatment. We have never seen the momentum we currently see behind Troa as it relates to Medicare. And you are seeing, you know, employees and patients use their voice and getting their insurance package to cover it. So we think it's actually going to be a good news story, particularly as more. disease states seem to be treated by GLP ones. And the argument around treating obesity effectively having such a wide-ranging impact on overall health, on concomitant conditions, whether that's diabetes, cardiovascular conditions, hypertension, you know, the list goes on is enormous. So that argument puts obesity in a special category of something that patients want care for, something that providers want to deliver care for. Yes. And something that I think ultimately will lower overall medical expenditures in the quest to achieve great health outcomes, which is what we all want.

So the fertility analogy is very interesting and also a big proponent of access to great fertility care. The behavioral health analogy is also interesting. It took some time for our collective communities to understand that those are medical conditions. They have implications for other medical conditions and for overall patient well-being, patient cost, patient access, patient return to work. I don't want to lose sight of something you slipped in there, which I just thought was so beautiful and important. But, you know, this idea of building a medical home where patients feel known well or well-known

to their care team is just really beautiful. It's something that I think every patient wants, every parent wants. for their child, you know, everybody wants their doctor to know them well. No matter how much technology is coming into health care, you want your doctor to feel like they know you well enough to make the right choices when they have many choices, which is kind of the incredible realm we're entering in obesity medicine. Your doctor's going to have many choices. And so choosing between those choices presumably requires knowing you well. So I just love that that mission, that name. We could end this just amazing conversation on the topic of building

a company to execute on that mission. How do you scale that? How do you blow it out to everybody who wants it? A lot of things have to go right, right? And they are, you know, one is, look, while obesity medicine is the fastest growing subspecialty in the U.S., we still have like 6,500 clinicians, most of whom don't practice obesity, 115 million American to need treatment. So that certainly can't be we just hire every obesity medicine certified physician in the country. So the first thing we're doing is hiring, you know, APP and physician PCPs, right, who have not had the training in obesity but are really excited to get it. And something we do is we train them in depth in the best practices of delivering obesity medicine. This is actually

something Dr. Fitch does across the country today with PCBs. We do that not only for our our own PCPs, but frankly, others in the community because we think it's so important for people to expand access for patients. So first is hiring non-specialized in addition to specialists, physicians so that we can treat more patients and deliver that carrot scale. The second is investing in the technology to help automate this stuff that doesn't matter. As you well know, so much of practicing medicine, and especially on the primary care side, so much of that is administratively burdensome, but not something that really deepens the relationship between the patient and the physician, right? It's things like getting referrals done, getting the imaging

in, getting the prior offs out. So things that are just necessary for care. So we're investing a lot in making sure that those pieces of our process are more automated so that we can scale and leave physicians the time to spend with their patients. And that's the last thing I would say is really a around physician clinical decision support and productivity. We are big believers in to serve the patient, you also have to serve the clinician. We know there is a huge burnout problem in the country. So how do we help clinicians work to the top of their licensure? We're working on a lot of systems, processes, and tools to really reduce that burden for

clinicians so that they are able to see more patients and spend time with those patients. what's something that you've learned as a founder about standing up a business to do all those things and kind of move closer to your vision around scale? What's something you've learned that they just don't teach in business school? You have to be the one who jumps. So I'll share a little story with you. I was in Hawaii and it was 8 a.m. And I had finally worked up the courage that I scheduled at a meeting with my CFO and CEO at 5 p.m. that day, which was a big deal. I was on the executive team to let them know I was going to step down as COL. This is at your prior company. This is at my fair company because I'm going to start knowing well. And I was dreading

that conversation because I love the company so much and love them. And at 8 a.m., right before I was going to head out to a farm, I got a text from Dr. Fitz that said, I know you're going to quit today. don't quit. What if we can't do it? This is many years ago now. And I, it was funny, I looked to my husband and I said, you know what, I'm always going to have to be the one who jumps. Like someone, some founder has to be the one who just says, I'm going off the cliff because someone's got to be the first one to do it. And I called Dr. Fitch, she does not mind me sharing this story. And I said, we're going to do it. And I'm going to be the first. first person who jumps and I know you'll end up following me. So I don't. And she did.

She jumped too. And she did. And she jumped. So I think like I underestimated and I don't mean to, I'm not a military vet or anything else, but I underestimated the amount of courage it takes as a founder that you focus so much on like what's all the day to day stuff and the long hours and the building the team. But it's like every day you really need to be the person who says I'm all in and I'm going to set the cultural tone that, like, we are going to get there. And I just, I didn't realize how important that would be on the path. I love that. That's a great note to end on.

It is incredible what you're building in such an important space on behalf of patients who want to access amazing, comprehensive obesity medicine. Thank you for joining us on the Raising Health podcast, and thank you for being all in. Thanks for having me. Thank you for listening to Raising Health. Raising Health is hosted and produced by me, Chris Tatiosian, and me, Olivia Webb. With the help of the bio and health team at A16Z, the show is edited by Phil Hegseth. If you want to suggest topics for future shows, you can reach us at RaisingHealth at A16Z.com.

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